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[Extensions of Remarks]
[Page E992]
From the Congressional Record Online through the Government Publishing Office [www.gpo.gov]
ACCURACY IN MEDICARE PHYSICIAN PAYMENT ACT OF 2013
______
HON. JIM McDERMOTT
of washington
in the house of representatives
Thursday, June 27, 2013
Mr. McDERMOTT. Mr. Speaker, I rise today to introduce the Accuracy in
Medicare Physician Payment Act of 2013. This bill will give the Centers
for Medicare and Medicaid Services (CMS) important tools and resources
to continue alleviating our dire shortage of primary care physicians.
As Congress tries to come together around the challenges of how to
repeal and replace the broken Sustainable Growth Rate formula, I want
to make sure that we do not neglect the Medicare physician fee schedule
and the impact it has on our physician workforce.
It is no mystery that relatively depressed salaries are driving new
doctors away from primary-care fields like family medicine and
pediatrics and into more lucrative specialties and subspecialties like
radiology and orthopedic surgery. I don't begrudge anyone for making
that choice; when I graduated from medical school 50 years ago I could
not have fathomed being loaded down with six figures of medical school
debt. And to be sure, we need talented specialists. But we have a
stubbornly small proportion of primary care doctors--just over 30
percent, when most experts agree that 50 percent is the ``sweet spot''
in terms of maximizing quality and minimizing cost.
I am proud that Congress gave primary care a shot in the arm in the
Affordable Care Act, under which Medicaid pays higher Medicare rates
for primary care through 2015, and Medicare makes quarterly incentive
payments to primary care physicians through 2017. The ACA also expanded
the National Health Service Corps, which eases the steep cost of
medical education for doctors and allied health practitioners willing
to practice in an underserved area after graduation. These are
meaningful steps, but to make more enduring progress in this area, I
believe that Medicare must repair structural inaccuracies in the
Medicare physician fee schedule that have eroded the value of primary
care. Simply put, Medicare contributes to this imbalance by underpaying
for the critical yet undervalued job of managing complex patients with
multiple chronic conditions and keeping them out of the emergency room
and hospital.
A major obstacle to reform is Medicare's continued reliance on a
committee of mostly specialist physicians to help set payment rates for
the 7,400 services on the Medicare physician fee schedule. Since 1991,
Medicare has outsourced its work of appraising the value of these
services to the AMA's Relative Value Scale Update Committee (RUC)--a
31-member panel of physicians who decide how services should be valued
and updated. Only a handful of the 31 committee members perform primary
care. The RUC meets in private and provides limited release of the
minutes of its proceedings. In formulating its recommendations, the RUC
also relies heavily on anecdotal and self-serving surveys, rather than
forensic evidence.
CMS has begun to update misvalued codes in the fee schedule, but it
needs more muscle and resources to do the job. This bill would
establish a panel of independent experts within CMS that would identify
the distortions in the fee schedule and develop evidence to justify
more accurate updates. Medicare could continue to request work from the
RUC, but the expert panel would both initiate such requests and review
RUC's work product. The panel members would not have a direct interest
in the fee schedule, and would include beneficiary representatives. It
would be subject to the Federal Advisory Committee Act, which requires
advisory bodies to hold open meetings and publish the minutes of such
meetings.
In addition to payment accuracy and fairness, this is also about
reining in a conflict of interest. After looking at this for several
years I believe that we give the physician specialty societies, through
the RUC, an undue influence on their own payments. In no other area--
whether it be hospitals, skilled nursing facilities, or any other
setting--does Medicare ask the providers to play such an active role in
setting their own reimbursement amounts. Medicare certainly needs
clinical expertise to evaluate the resources necessary to perform
physician services but should not look to an outside organization whose
members directly benefit from the fee schedule to apportion some $70
billion in annual public spending, without some checks and balances. No
matter how well-intentioned, such a system contains structural biases
that need safeguards to prevent abuse.
Medicare is not only one of America's most important social insurance
programs and a bulwark of the middle class, it also establishes
economic incentives that ripple through all of health care and
contribute to our shortage of primary care physicians. As we continue
to pursue a permanent doc fix, let's also talk about how we will use
Medicare to incentivize the appropriate mix of physicians in the
workforce to serve beneficiaries and the public health.
____________________